Informed Consent

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					   Beverly Anne Abbott, MA, LPC
                           Licensed Professional Counselor
                          PO Box 8788, Longview, TX 75607
                        11968 FM 2011, Henderson, TX 75652

                                             Client Disclosure Statement—
                                             Information and Consent

You have taken your first step. You are here. For whatever reason, you have chosen to seek changes in
your life. I am delighted that you have chosen me to walk this path with you. Please take a moment to
thoroughly read and understand the following important information. It is vital that from the onset of
our relationship, we have a mutual understanding and are in agreement with each other.

            In general, everything in our counseling sessions I will hold in the strictest confidence. Our
   conversations and records of your treatment are your privilege, protected by both state law and my
   profession’s ethical principles. But I cannot promise that everything you tell me will never be revealed to
   someone else. There are some times when the law requires me to tell things to others. There are also
   some other limits on our confidentiality. We need to discuss these, because I want you to understand
   clearly what I can and cannot keep confidential. You need to know about these rules now, so that you
   don’t tell me something as a “secret” that I cannot keep secret. These are very important issues, so
   please read these pages carefully. I have a copy of this information should you like to keep it. You will
   be asked to sign a statement of your understanding of this information, so if you have questions please
   do not hesitate to ask.

   1. When you or other persons are in physical danger, the law requires me to tell others about it.
   If I come to believe that you are threatening serious harm to another person, I am required to try to
   protect that person. I may have to tell the person and the police, or perhaps try to have you put in a
   hospital. If you seriously threaten or act in a way that is very likely to harm yourself, I may have to seek
   a hospital for you, or to call on your family members or others who can help protect you. If such a
   situation does come up, I will fully discuss the situation with you before I do anything, unless there is a
   very strong reason not to. In an emergency where your life or health is in danger, and I cannot get your
   consent, I may give another professional some information to protect your life. I will try to get your
   permission first, and I will discuss this with you as soon as possible afterwards. If I believe or suspect
   that you are abusing a child, an elderly person, or a disabled person I must file a report with a state
   agency. To “abuse” means to neglect, hurt, or sexually molest another person. I do not have any legal
   power to investigate the situation to find out all the facts. The state agency will investigate. If this might
   be your situation, we should discuss the legal aspects in detail before you tell me anything about these
   topics. You may also want to talk to your lawyer. In any of these situations, I would reveal only the
   information that is needed to protect you or the other person. I would not tell everything you have told

2. In general, if you become involved in a court case or proceeding, you can prevent me from testifying
in court about what you have told me. This is called “privilege,” and it is your choice to prevent me from
testifying or to allow me to do so. However, there are some situations where a judge or court may
require me to testify:
In child custody or adoption proceedings, where your fitness as a parent is questioned or in doubt.
In cases where your emotional or mental condition is important information for a court’s decision.
During a malpractice case or an investigation of me or another therapist by a professional group.
In a civil commitment hearing to decide if you will be admitted to or continued in a psychiatric hospital.
When you are seeing me for court-ordered evaluations or treatment. In this case we need to discuss
confidentiality fully, because you don’t have to tell me what you don’t want the court to find out
through my report.

3. There are a few other things you must know about confidentiality and your treatment:
I may sometimes consult (talk) with another professional about your treatment. This other person is also
required by professional ethics to keep your information confidential. Likewise, when I am out of town
or unavailable, another therapist will be available to help my clients. I must give him or her some
information about my clients, like you. I am required to keep records of your treatment, such as the
notes I take when we meet. You have a right to review these records with me. If something in the record
might seriously upset you, I may leave it out, but I will fully explain my reasons to you.

4. Here is what you need to know about confidentiality in regard to insurance and money matters:
If you use your health insurance to pay a part of my fees, insurance companies require some
information about our therapy. Insurers such as Blue Cross/Blue Shield or managed care organizations
ask for much information about you and your symptoms, as well as a detailed treatment plan.
It is against the law for insurers to release information about our office visits to anyone without your
written permission. Although I believe the insurance company will act morally and legally, I cannot
control who sees this information at the insurer’s office. You cannot be required to release more
information just to get payments. If you have been sent to me by your employer’s Employee Assistance
Program, the program’s staffers may require some information. Again, I believe that they will act
morally and legally, but I cannot control who sees this information at their offices. If this is your
situation, let us fully discuss my agreement with your employer or the program before we talk further.
If your account with me is unpaid and we have not arranged a payment plan, I can use legal means to
get paid. The only information I will give to the court, a collection agency, or a lawyer will be your name
and address, the dates we met for professional services, and the amount due to me.

5. Children and families create some special confidentiality questions.
When I treat children under the age of about 10, I must tell their parents or guardians whatever they ask
me. As children grow more able to understand and choose, they assume legal rights. For those between
the ages of 10 and 18, most of the details in things they tell me will be treated as confidential. However,
parents or guardians do have the right to general information, including how therapy is going. They
need to be able to make well-informed decisions about therapy. I may also have to tell parents or
guardians some information about other family members that I am told. This is especially true if these
others’ actions put them or others in any danger. In cases where I treat several members of a family
(parents and children or other relatives), the confidentiality situation can become very complicated. I
may have different duties toward different family members. At the start of our treatment, we must all
have a clear understanding of our purposes and my role. Then we can be clear about any limits on
confidentiality that may exist. If you tell me something your spouse does not know, and not knowing

this could harm him or her, I cannot promise to keep it confidential. I will work with you to decide on the
best long-term way to handle situations like this. If you and your spouse have a custody dispute, or a
court custody hearing is coming up, I will need to know about it. My professional ethics prevent me from
doing both therapy and custody evaluations. If you are seeing me for marriage counseling, you must
agree at the start of treatment that if you eventually decide to divorce, you will not request my
testimony for either side. The court, however, may order me to testify. At the start of family treatment,
we must also specify which members of the family must sign a release form for the common record I
create in the therapy or therapies. (See point 7b, below.)

6. Confidentiality in group therapy is also a special situation.
In group therapy, the other members of the group are not therapists. They do not have the same ethics
and laws that I have to work under. You cannot be certain that they will always keep what you say in the
group confidential.

7. Finally, here are a few other points:
I will not record our therapy sessions on audiotape or videotape without your written permission.
If you want me to send information about our therapy to someone else, you must sign a “release-of-
records” form. I have copies you can see, so you will know what is involved. Any information that you
also share outside of therapy, willingly and publicly, will not be considered protected or confidential by a

Philosophy & Approach

You are unique. No other client will have the same needs as you do, and therefore I will treat you based
upon the therapeutic goals that you and I establish in our initial session(s). I do not take on clients
whom I cannot help using the techniques I have available. It is my belief that a successful counseling
experience will involve a lot of work on your part, both in the therapy session and outside. Of course
you are never required to complete any “homework” that might be assigned to you, but I do believe
that these exercises will only enhance your progress. Specific examples of “homework” may include,
but are not limited to: journaling, reading a certain book or passage recommended, workbook entries,
listening to tapes, attending meetings, etc.
         Counseling, as with any other powerful intervention, has both benefits and risks. For example
therapy may temporarily result in an increase in both pleasant and unpleasant emotions. Such
unpleasant emotions might include experiencing uncomfortable levels of feelings such as sadness, guilt,
anxiety, and anger, among others, or might lead to increased personal conflict (for example therapy may
not keep a troubled relationship intact). Often therapy leads to a significant reduction in stress, the
resolution of old conflicts and healing of old wounds, or to personal growth and self-knowledge.
         Once we have agreed to begin our sessions, at no time will I acknowledge the existence of our
relationship outside of the counseling session (unless initiated by you). Ours will be a professional,
therapeutic relationship and it is my belief that any other relationship would be counterproductive to
the purposes of counseling.

Fees for services rendered/Methods of Payment

Fees are based on a sliding scale dependent upon gross family income. According to the Office of the
Inspector General, total gross family income MUST be documented: a tax return or a copy of each
contributing family members’ W2 form are acceptable forms of documentation. The same applies

whether it is an individual, family, or couple. Appointments are scheduled based on your treatment
needs and availability. The appointment time you schedule is reserved exclusively for you. If you cannot
make your scheduled time, please give at least 24 hours notice, more if possible. Please remember that
my income is based upon scheduled sessions so with the exception of extreme emergencies (up to my
discretion), missed appointments or cancelled appointments without 24 hour notice may be subjected
to the regular session fees and must be paid prior to rescheduling.

A monthly fee of 1% of the unpaid balance will be charged each month an account is overdue. Special
billing arrangements may be granted on an individual basis, but do not cancel your obligation to pay for
services received. If it is necessary to enlist an outside agency or service to collect unpaid charges or
handle a bill dispute, the client / responsible party is responsible for paying the balance due plus late
fees as well as any collection, legal expenses, or court-ordered fees.

Complaint Procedures

        If you are dissatisfied with any aspect of our work together, please inform me immediately. If
you feel that you have been treated unfairly or unethically, by me or any other professional in my field,
and are not comfortable resolving the conflict with me you can contact the Texas Board of Licensed
Professional Counselors:

Complaints Management and Investigative Section
P.O. Box 141369
Austin, Texas 78714-1369

________ Treatment: I have read and understand the disclosure statement provided to me. I
understand my rights and responsibilities. I consent for my self/my dependent to participate in
evaluation and treatment, and I understand that I may refuse or terminate services at any time.
_________ Confidentiality: I have read and understood the information regarding
confidentiality as explained in the disclosure statement. I have had an opportunity to discuss
my concerns and questions with my therapist. A copy of the limits of confidentiality was also
made available for my personal records.
__________ Fees: After clear explanation of the fee policy and structure, I agree to adhere to
the policies and procedures concerning payment of services rendered.
_________ Appointments: I understand the appointment policies and will make every effort to
make the scheduled appointment time. If the need to cancel or reschedule arises, I will make
every effort to do so 24 hours prior to the scheduled time. I also understand that I may be
charged a “no show” fee if I do not call to cancel my appointment and miss my appointment.
_________ Email: I understand and agree to the conditions set forth in the Use of E-mail in
Counselor/Client Relationship form.
_________ Emergencies: I have received a copy of the Emergency Contact sheet that provides
me with information on how to get assistance in case of an emergency during the day or after
_________ Client Rights: I have read and understand the client’s rights information in the
disclosure statement.
_________ HIPAA (Privacy Practices): I have had a chance to read and understand the notice of
privacy practices.
_________ HIPAA (Consent for Disclosure): I have read the consent policy and agree to its terms. I am
also acknowledging that I have received a copy of the notice.

  Beverly Anne Abbott, MA, LPC                                                                  Date


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